|Year : 2022 | Volume
| Issue : 2 | Page : 157-159
Patient safety – Are we doing enough?
Healthcare, QuessCorp.; Ramaiah Medical College and Hospital; Akash Medical College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||15-Nov-2022|
|Date of Acceptance||28-Nov-2022|
|Date of Web Publication||23-Dec-2022|
Dr. Naresh Shetty
Quess Corp., Healthcare Division, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shetty N. Patient safety – Are we doing enough?. Arch Med Health Sci 2022;10:157-9
| Introduction|| |
Health care is becoming increasingly hazardous, and the last few decades have shown significant medical errors occurring in hospitals. Patients are at an increased risk of adverse outcomes both in terms of morbidity and mortality and pay higher costs. Many of these are totally avoidable. “To err is human” is unacceptable in a hospital setting, where the choices are between life and death. A report from the Institute of Medicine has clearly stated medical errors as the third leading cause of death. It causes an increase in hospital stay and health expenditure by about 35–50 billion US dollars in the USA alone. The need for patient safety and improvement in safety standards across hospitals has been pushed aggressively worldwide, as also the need for checklists and standard operating procedures. The example of air travel becoming safe due to a mandated safety checklist before take-off and a continuous effort toward zero errors has now become a gold standard. Comparing air travel to health industry statistics in today's scenario would mean three jumbo jets crashing every other day. The last two decades have seen a lot of effort toward quality care. Ensuring patient safety as well as health-care personnel are national objectives for health systems in both developed and developing countries, in response to research highlighting poor quality and media reports.
| The Global Scenario|| |
Numerous studies have confirmed that medical error is prevalent not only in underdeveloped but also very much in developed health system. In Australia, around 140,000 cases of medical errors occur per year, with almost 2000–4000 deaths as a result. In the United States, however, medical errors result in as high as 251,000 deaths annually.
In 2002, the WHO member states agreed on a World Health Assembly resolution on patient safety that prioritized global health, and later in 2019, matters such as developing global norms and standards for patient safety, promoting evidence-based policies, international recognition of excellence in patient safety, and assisting countries in several key areas have been discussed among policymakers. The National Health Service has spent around 2.4 billion pounds on clinical negligence claims in 2018–2019 and has been tripling every decade since 2009.
A decade-old survey reported on the views of public regarding deaths due to medical negligence, and since then, new efforts have been introduced to reduce medical errors.
| The Indian Scenario|| |
Not much data are available about the incidence of medical errors in India. However, the situation is both alarming and dangerous. The problem is further complicated by the lack of culture of reporting and recording medical errors in India. In India, though precise data are not available regarding medical errors, it is estimated that around 5.2 million injuries occur due to medical errors, resulting in around 3 million preventable deaths every year., For every 100 hospitalizations, an average of 12.7 adverse events occur. The need to have better processes and system to identify and reduce errors has become increasingly important. There has been a definite push from the government toward accreditations and with increase in medical tourism, lot of private hospitals have ensured the highest international standards. However, the scenario in government hospitals, district hospitals, as well as primary health centers is frightening. Shortage of workforce and funds with overcrowding and poor infrastructure put quality at stake.
The recent Covid pandemic showed the public health in such poor light, and one hoped that more funds were allotted to the creaking healthcare system than just 2% of its Gross Domestic Product. Although lack of funds was an issue, cases of medical negligence, including the use of nonrecommended medications, charging exorbitant prices for vaccines were some of the incidents that occurred in India during the COVID-19 pandemic. The gulf between the available health care and standard of care is huge and mostly compromised because of affordability and accessibility. The opening of medical colleges at the district level is one of the many plans of the government to provide a reasonably good health system. However, the system for ensuring the safety of patients as well as safety of health-care workers (HCW) remains nonexistent. This has forced a lot of people to flock the private setups wherein the cost is exorbitant and out of reach for the weaker sections of the community.
| Challenges in Health Care|| |
At present, health-care services have insurmountable challenges with respect to patient safety:
- Unsafe and poor health-care quality causes inconvenience including injuries or death in millions of patients in low- and middle-income countries
- It is estimated that in high-income countries, about 1 in 10 patients could get harmed while receiving hospital care, while in low- and middle-income countries, over a 134 million adverse events have occurred in hospitals, contributing to 2.6 million deaths annually,
- WHO reported medication errors as a major cause of injury and unnecessary harm in health-care systems. Globally, medication errors alone cost around US$ 42 billion annually
- Health-care associated and hospital acquired infections (HAI) prevalent in high-income countries is about 7.5% and between 5.7% and 19.2% in low- and middle-income countries
- Unsafe surgical procedures have caused complications in up to 18% of patients in intensive care units and10% of patients undergoing surgery
- Unhygienic and unsafe injection practices also can transmit infections, including HIV and Hepatitis B and C, and put the patients and HCW under direct risk. This has accounted for an estimated 1.67 million Hepatitis B infections, 315 210 Hepatitis C, and 33,877 HIV infections in South Asia alone
- Diagnostic errors have been reported to occur in about 5% of adults every year in ambulatory care settings, greater than half of which can potentially cause severe damage; most people are said to suffer a diagnostic error in their lifetime
- Unsafe transfusion practices also increase the risk of adverse transfusion reactions and transmission of infections among patients. A recent study in the UK highlighted the risk of death to be 1 in 117 000 due to transfusion errors and serious harm in 1 in 21 000 due to blood components issued
- Radiation errors involving overexposure to radiation and cases of wrong-patient and wrong-site identification, and an estimated 55% of incidents occurred at planning stage and 45% due to instrumentation
- Sepsis due to nosocomial infections arising from surgical procedures, catheters, and materials inhaled into lungs are also a cause of concern.
Besides the number of challenges faced, a major factor is the attitude, discipline, and response of health-care provider. This is totally dependent on individual training and experience, their skills and response during a critical situation. There is also an insurmountable influence of commercial health-care systems, health insurance, and pharmaceutical companies transforming the practice of medicine to a practice for profit maximization. Other important factors to be considered would be inadequate infrastructure, unfamiliar settings, and delayed hospitalization. It is necessary to sensitize the HCW about the prevalence and seriousness of medical errors and how any further delay can cause increase in both morbidity and mortality. Another cause of system failure is due to poor communication, vague lines of authority of physicians, nurses, and other care providers, and lack of teamwork. In addition, inadequate awareness about errors hinders the evaluation of contributing causes and in turn improvement strategies. The doctor–patient relationship seems to be de-railing, as the former's approach toward the latter has been “reductionist,” in that they see patients not as a human but as an organ system.
| Change in Strategy|| |
Managing any medical error is quite complex. The individual involved in the care at the time of the incident is held responsible, resulting in “blame game.” Individuals are blamed or suspended for an error which may not be intentional. The fear of this witch-hunting makes people not to report errors or adverse events in the institution. This results in larger errors which are more likely because of bad system and not bad people.
System improvements cannot happen as long as the focus is on blaming individuals. According to the National Patient Safety Implementation framework (2018–2025), India, in a hospital setting the patient safety consists of four definite areas (a) health-care providers, (b) health-care recipients, (c) infrastructure and facilities, and (d) quality parameters and feedback system. Strengthening these areas will ensure better compliance and more honest robust system. There is a need to address the incident by root cause analysis to identify cause of the error and ensuring corrective and preventive actions. Reducing the errors and defining the weak areas should be the motto as is the practice in industry and the aviation sector. Furthermore, patient participation is established as a key determinant to improve patient safety and prevent medical errors. A major campaign is required to convince physicians and health-care workers to understand the value of patient participation in preventing medical errors and in improvement of health-care quality. It is necessary to reflect from one's own mistakes, rather than sweeping the errors under the rug by the individual and the hospital management because, at the end of the day, it is a matter of protecting another human life!
| Time to Change is Now|| |
There is overwhelming evidence that has highlighted harm to a significant number of patients from their health care either resulting in permanent injury, increased length of stay in hospitals, and even death. Over the last decade, we have learned that adverse events occur not because of bad people but because of system failure. For successful treatment of each patient, the health-care system depends on a range of factors, not just the competence of an individual health-care provider. With so many health-care providers (doctors, nurses, pharmacists, social workers, dieticians, and others) involved, there is clearly a need for a system that can facilitate team effort with rapid and seamless information designed to provide quality care with a human touch.
Patient safety is an issue for all the countries that deliver health services, whether they are privately commissioned or funded by the government. Wrong side surgery, incorrect medication, illogical antibiotic prescription, and adverse drug reactions can all cause unnecessary adverse events. Adding to that, poor surveillance, lack of communication, and inadequate usage of technology can cause unnecessary harm to the patient and the health care provider. Good clinical practices, following SOP and providing good outcomes for patient will be the expected norm from health care providers. There is a fear that providing patient safety will involve increase in financial spending, which is not true. Rather, it involves a commitment of individuals to good clinical and safe practices. There is a need to sensitize people to be more system driven, enhance better documentation, provide regular training, and report errors, or adverse events in the future. This will enable a more pragmatic approach toward reducing medical errors and provide a very safe patient care in a safe environment.
| Conclusion|| |
Despite the beneficial impact of modern medicine in alleviating illness, hospitals being unsafe for the very purpose of “healing,” as such, is now unraveling. Instead, they are places fraught with the risk of patient harm. Major areas of concern are hospital-associated infections (HAI), unsafe surgeries, unsafe injections, safe births, medication safety, blood safety, and faulty medical devices.
One important response to this realization has been the growth of interest in patient safety and the global awareness fostered by the World Health Organization's World Alliance for Patient Safety. Adoption of common strategy, good practices, and developing indicators focusing on the specific priorities of each country and region needs to be implemented. The challenges remain undiminished and in fact, new threats are emerging due to population aging, along with newer treatment trends and technologies which must be dealt along with existing unresolved issues.
| References|| |
Kohn LT, Corrigan JM, Donaldson DM. Institute of medicine (US) committee on quality of health care in America. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 2000.
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016;353:i2139.
Ovretveit J. What are the Best Strategies for Ensuring Quality in Hospitals? Copenhagen: WHO Regional Office for Europe (Health Evidence Network Report); 2003.
Scott IA, Crock C. Diagnostic error: Incidence, impacts, causes and preventive strategies. Med J Aust 2020;213:302-5.e2.
Anderson JG, Abrahamson K. Your Health Care May Kill You: Medical Errors. Stud Health Technol Inform 2017;234:13-7.
Yau CWH, Leigh B, Liberati E, Punch D, Dixon-Woods M, Draycott T. Clinical negligence costs: Taking action to safeguard NHS sustainability. BMJ 2020;368:m552.
Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al
. Views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:1933-40.
Reddy NG. Prevention of errors in health care-patient (Medical customer) safety Introduction. J Basic Clin Res 2017;4:19-23.
Sharma G, Awasthi S, Dixit A, Sharma G. Patient safety risk assessment and risk management: A review on Indian hospitals. Chronicles Young Sci 2011;2:186.
Ghebreyesus TA. Global Action on Patient Safety. [Online]. World Health Organization; 2019.
Voidazan S, Albu S, Toth R, Grigorescu B, Rachita A, Moldovan I. Healthcare associated infections-a new pathology in medical practice? Int J Environ Res Public Health 2020;17:E760.
Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al
. Prevalence, severity, and nature of preventable patient harm across medical care settings: Systematic review and meta-analysis. BMJ 2019;366:l4185.
Altaf A. Unsafe injection practices by medical practitioners in South Asia associated with hepatitis and HIV outbreaks. J Infect 2018;1:1-3.
Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf 2017;26:484-94.
Bolton-Maggs PH, Watt A. Transfusion errors – Can they be eliminated? Br J Haematol 2020;189:9-20.
Marcolongo A, Cristofaro G, Mariotto A, Mascarin M, Puglisi F. Risks in Oncology and Radiation Therapy. In: Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, editors. Textbook of Patient Safety and Clinical Risk Management. Denmark: Springer, Cham; 2021. p. 253-73.
Tattoli L, Dell'Erba A, Ferorelli D, Gasbarro A, Solarino B. Sepsis and nosocomial infections: The role of medico-legal experts in Italy. Antibiotics (Basel) 2019;8:199.
Shelley BP. “Primum non nocere,” harmful medical mistakes, hubris syndrome, and human fallibility; Getting to the heart of the matter. Arch Med Heal Sci 2018;6:195.
Emanuel L, Berwick D, Conway J, Combes J, Hatlie M, Leape L, et al
. What exactly is patient safety? J Med Regul 2011;95:13-24.
Ministry of Health and Family Affairs. National Patient Safety Implementation Framework (2018-2025). India: Government of India; 2018.
Singh G, Patel RH, Boster J. Root Cause Analysis and Medical Error Prevention. Online. StatPearls; 2022.